The emergency department (ED) is likely to be the most unsafe ambulatory care setting for patients. By nature, ED care is transitional and more likely than other ambulatory locations to be influenced by multiple factors such as variable patient acuity, lack of patient information, and interruptions to patient flow. Care within the ED is also complex as a result of the many people, decisions, and overlapping processes of care that must be integrated both within and outside of the ED. Until recently, knowledge about the number and types of errors and adverse events occurring within the ED has been limited, with the majority of studies focusing on missed diagnoses of high-stakes conditions. New data from our study, Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED), reveal that errors and adverse events occur in 59% and 2.3% of patient visits, respectively. These data also suggest that the greatest risks to patient safety in the ED involve gaps in care related to diagnostic study processing and medication delivery. The gaps in care occur when communication and coordination between clinicians and across disciplines fail and are particularly notable across transitions of care and for patients with complex care needs and conditions, and prolonged stays. The important findings elicited from our ERASED grant now enable us to systematically develop and implement a novel intervention strategy to reduce the risk of harm associated with gaps in care. The specific aims of this project are to: (1) develop a check-list based cognitive tool to reduce the risks of gaps in care related to diagnostic study processes and medication delivery in the ED; (2) implement the cognitive tool in the ED; (3) evaluate the ability of the status tracking tool to reduce the risks of information gaps in the ED; and (4) develop and disseminate a comprehensive "toolkit" to facilitate implementation of a status tracking tool for diagnostic tests and medication delivery in EDs at other institutions. Each of the first three aims will be completed at two different sites that differ significantly in their use of automation. By validating the toolkit in both a large academic medical center and a smaller community hospital, the results will be generalizable to most EDs in the United States. There are over 110 million visits to the ED annually, with an estimated 71% requiring at least one diagnostic test and 77% requiring a drug while in the ED or prescribed at discharge. Any reductions in risk in either of these processes have the potential to affect a great number of patients. [unreadable] [unreadable] PUBLIC HEALTH RELEVANCE: The greatest risks for patient harm in the emergency department are gaps in care related to diagnostic study processing and medication delivery. By introducing a tool to improve coordination of diagnostic testing and medication delivery across disciplines and across handoffs, these risks will be reduced. The project has the potential to advance the safety of care for the millions of people who use the emergency department every year. [unreadable] [unreadable] [unreadable]